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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME1 600 East Main Street, Stockton, CA 95202-30/-y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name:^� /W / Page —�— of Facility Address: City: Inspectio il Date: FA #: PR #: Pro m ent: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: a51 le 13 (p (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: (!;;,q S Total Capacity: b V gallons .10 ( er tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAM A5-1 le (� (>250 gallons) (>55 gallons and <250 gallons) � 2 Product Type: 14i. Total Capacity: D -P-0 gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) Containers (2821) #of Containers: TA#: au le f 3 <g 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: lfl/ /, —� N J j Fi�� 1•L Total Capacity: 1Z, 09-0 gallons �S (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 15 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered /7 Dat By Initial: By Initial: (/l✓�C(/ r EHD 28-01 01/16/08